This article is part of State of Health, a series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from theMichigan Health Endowment Fund.

Understanding a doctor's diagnosis or an insurance company's explanation of benefits can be difficult for many who grew up in the United States speaking English. But for immigrants, challenges to receiving and understanding good care are exponentially greater.

Anna Hill, attorney for the Michigan Immigrant Rights Center, says immigrant parents are often questioned aggressively about their immigration status while applying for Medicaid for their American-born children.

Anna Hill

"Parents are being asked about where they're from and other questions meant to intimidate or harass them or frighten them away from seeking benefits for their children who are eligible and need basic support," Hill says.

That's just one of many barriers to health equity that immigrants in Michigan face every day. Immigration status, stigma, language and cultural differences, and uncertainty and stress about changing laws and regulations all play a role in immigrants' ability to achieve good health.

Accessing healthcare for new Americans

Ruth Kraut, program administrator for the Washtenaw Health Plan (WHP), says immigrants' access to healthcare and health insurance depends on a number of factors.

"There is a set of issues around access depending on immigration status, since they may be eligible for some benefits and not others, and, in fact, the benefits they're eligible for might be different state by state," Kraut says. "Michigan covers fewer benefits than Illinois or New York for certain populations, so if you're coming to Michigan from one of those states, you might have experienced different rules."

Ruth Kraut

On top of that, different members of the same family may qualify for different benefits based on immigration status and age. Kraut notes that healthcare in the United States tends to be "family-based," but many families include immigrant adults who are not yet naturalized, while their children were born in the U.S. Or perhaps one child was born in the U.S. and one wasn't.

In general, refugees, asylum-seekers, and most people who have had a permanent resident card for over five years are eligible for everything a citizen would be eligible for, including full Medicaid.

Kraut says most immigrants who have documents like a work permit or some other kind of visa, or who have had their green cards for less than five years, can get healthcare through healthcare.gov. In Michigan, however, the only Medicaid coverage they're eligible for is emergency coverage.

Employer coverage is a possibility for almost any immigration status, but "if they don't have their own social security number, there are challenges getting private insurance," Hill says.

Uncertainty about changing rules can add another layer of difficulty in achieving good health. For instance, the Trump administration recently proposed an expansion of the previously narrowly defined "public charge" policy, requiring that immigrants "not depend on public resources to meet their needs." As a result, Kraut says an immigrant woman she was working with misunderstood the changes and dropped her marketplace health insurance.

"A few weeks later, she hit her head and went to the emergency room," Kraut says. "She needed an MRI and received a $5,000 bill."

Health equity isn't just about access to healthcare, but to many "upstream" factors that affect health outcomes, including socioeconomic status, education, and social support network. Immigrants are often disadvantaged in those areas as well.

"Refugees are facing a whole range of mental health challenges from anxiety and depression to post-traumatic stress syndrome to psychosis as a result of experience (in their home countries)," says Farah Erzouki, public health manager with ACCESS Community Health and Research Center, a Dearborn-based nonprofit that provides advocacy and resources to Arab-Americans. "It goes so much deeper than a language barrier."

Farah Erzouki

She notes that cultural differences mean that some immigrants will see less value in preventive care, thus ending up at an emergency room or health clinic only after a health situation becomes dire. People from certain cultural backgrounds might be nervous about looking into mental health services as well.

"For Arab-Americans in general, mental health has a stigma attached to it, and they don't talk about it," Erzouki says. "People in our community are just starting to see the importance of making sure mental health is as prioritized as physical health."

The program receives a small percentage of its funding from the school system, but the rest comes from grants and other private sources.

About 35 states currently offer immigrant children full Medicaid coverage, but Michigan provides them emergency services only, according to Sarah Peslar, social worker with HSBHC. However, Peslar says HSBHC provides much more than emergency care.

"We can see kids and get them immunizations and physical exams," she says. "They can't even register for school unless they've had immunizations."

Sarah Peslar

Collaborations with other healthcare providers and universities allow HSBHC to provide specialty services like mental health consultations, dental cleanings, and eyeglasses as well.

ACCESS also provides a full spectrum of health and human services, including mental and physical health care, social work, workforce development, and advocacy.

ACCESS' healthcare division runs a medical clinic that covers the full spectrum of care, from primary care and pharmacy to a partnership with Henry Ford Health System that provides OB/GYN services. The healthcare division also runs a breastfeeding and nutrition support program for pregnant women and new mothers.

Inside ACCESS

"We pride ourselves on serving regardless of the ability to pay," Erzouki says. "We'll work with you if you have insurance, and if someone is uninsured, we'll work on a repayment schedule that's feasible for them."

On the legislative front, Hill says the Michigan Immigrant Rights Center in 2019 will advocate waiving the five-year waiting period for immigrant children to receive full Medicaid coverage. Expanding that coverage will be an improvement for a small but especially vulnerable group of children.

"If a state court makes a finding that (an immigrant child) has experienced abuse, abandonment, or neglect, they can apply for that special immigrant juvenile status, and that can lead to a green card if approved," Hill says. Under current law, "those kids would face that five-year waiting period before they'd be eligible for full Medicaid coverage."

Kraut says most advocacy groups see healthcare as a right, not a privilege. But when trying to convince legislators and other officials of the benefits of expanding coverage for immigrants, there's both a humanitarian and a fiscal argument to be made. If someone has an untreated health condition, that can affect their ability to work and make money.

"There are great studies on the benefits of Medicaid expansion," Kraut says. "When people are enrolled, it allows them to work more hours and be healthier. It can make a real difference."

Photos of Hamtramck School Based Health Center patients courtesy of Children's Hospital of Michigan Foundation. All other photos by Nick Hagen.